Prominent health policy expert offers his views on reform’s future

The annual California Health Journalism Fellowship kicked off a packed week of programs with a wide-ranging conversation between Gerald Kominski, director of UCLA's Center for Health Policy Research, and Anna Gorman of Kaiser Health News.

From the pending Supreme Court case to narrow provider networks and the remaining uninsured, their thought-provoking exchange hit upon many of health reform’s biggest themes at the moment. Here are a few highlights from the discussion on Sunday.

King v. Burwell ‘a very real threat’

The King v. Burwell case is on the minds of many this week, as the Supreme Court starts hearing oral arguments in the case Wednesday morning.

At issue is whether the federal government can provide premium subsidies in states that didn’t set up their own exchanges. “The case is a severe challenge to the Affordable Care Act, and I think that it’s a very real threat,” Kominski said.

The origins of the case can partly be explained by the unusual circumstances of the law’s passage, Kominski told fellows. After Democratic Sen. Ted Kennedy died in August 2009, the Democrats abruptly lost their 60-vote supermajority. Democrats in the House were forced to pass the Senate version of the bill, without the luxury of smoothing out the bill’s language in a Congressional conference committee.

“This would’ve been ironed out in a different time and place, but the unusual circumstances under which the law was enacted prohibited that from happening, so this inconsistency is still in there,” Kominski said.

But if the law’s legal challengers prevail (a decision is expected at the end of June), it remains unclear how the politics would then play out. As Gorman asked, “Could this give fuel to Republicans to repeal the law, or would this be bad for Republicans who have so many constituents who now have been reliant on health insurance with subsidies?”

Kominski, stressing his lack of a crystal ball, said: “I think it will embolden the most conservative elements of the Republican Party if the Supreme Court rules the subsidies are unconstitutional. What will happen is that the party, especially the Tea Party portion, will say, ‘OK, we have majorities in the House and Senate. Now all we need is a Republican president in 2016 and we can get rid of this law.'”

But, Kominski added: “In the meantime, there will a political price paid for the 8 million people who will lose subsidies.”

“The vast majority of them would find health insurance unaffordable again, and we would go back to what one my colleagues described recently as ‘the bad old days.’”

Fallout from ‘narrow networks’

Problems stemming from “narrow networks” have been a source of deep frustration for many Obamacare enrollees — and a rich source of reform-related horror stories for health journalists.

“One of the consequences of the Affordable Care Act is that for insurance to be more affordable in the exchange, insurance companies have contracted with fewer doctors and fewer hospitals,” Kominski said. In an effort to keep insurance premiums down, insurers have often made networks smaller than many would like. And clear information on which doctors are available in which plans has been sorely lacking.

“Two of the most expensive hospitals in Los Angeles County are UCLA and Cedars-Sinai,” Kominski said. “Those two hospitals are not included in the networks of most plans that are provided by Covered California.

“Now does that mean that residents of Los Angeles County who buy Covered California health insurance don’t have access to the best hospitals? You can make an argument that for a limited range of patients with rare conditions, they don’t have access to the best possible care because those two hospitals aren’t in the network. For the vast majority of hospitalizations, the absence of those hospitals from the networks probably doesn’t matter.”

For Kominski, the discussion has gotten personal. A colleague of his was recently diagnosed with a rare uterine cancer, and her Covered California policy “prevents access to two of the best hospitals in the country,” he said, referring to UCLA and Cedars.

“For someone in that situation, the only option is to go out-of-network, and the cost of out-of-network care is extraordinary,” he said. “It’s very high.”

The story of narrow networks is a topic worthy of more coverage, he stressed.

“I do think the narrow networks are an unintended consequence of the law,” he said. “I don’t think anybody that I know will say that, ‘Yes, we knew this would happen, that insurance companies were going to negotiate much tougher with doctors and hospitals, and as a result there would be fewer doctors and hospitals willing to accept these plans.’”

Other stories worthy of more press

Residual uninsured: “I think that the stories of why people are not signing up for insurance are worth telling. I think that it’s worth understanding what some of the concerns and perhaps fears are of people who are staying out of the marketplace, who are turning down financial support or free care.”

Some in the Latino community have voiced concerns that signing up for marketplace insurance could alert federal authorities of their families’ mixed-immigration status, despite assurances to the contrary from state exchange officials. Are those concerns subsiding? That’s a question worth looking at in your community.

Bronze plans: Kominski voiced real concerns about the value of the bronze plans sold on the insurance marketplace. Such plans “are really catastrophic plans in my opinion,” he said.

Bronze plans require high out-of pocket costs before enrollees reach their deductible. They can be a lifeline in an unexpected emergency, but they offer few benefits under routine circumstances.

“I feel like the bronze plans are not such a good deal for people, that maybe we should have started with the silver as the lowest level, not bronze,” Kominski said.

“The reality is that the vast majority of Californians don’t spend $5,000 a year for health care. You have to be hospitalized, and your chances of being hospitalized are on average about 6 percent — it’s not that high.”